Patients with uncontrolled type 2 diabetes benefited from an online disease management program in a randomized controlled trial conducted at the Palo Alto Medical Foundation (PAMF) in northern California. Equally important, the study showed that a nurse-led, multidisciplinary care team could use such a program to manage a population of diabetic patients, the report concluded.

In the 12-month trial, the 189 patients in the control group received usual care. The 193 patients in the intervention group used a wireless home glucometer that uploaded readings through a smartphone to PAMF's electronic health records (EHR) system. The patients could view the data in their Web-based personal health record and log in information relevant to diabetes management, such as dietary intake, physical activity, home blood pressure, insulin doses and weight. Nurse case managers and a registered dietician communicated with patients primarily through secure online messaging. Patients received regular feedback about their clinical variables and were provided educational materials online.

After six months, the intervention group had significantly better diabetes control than the control group, as measured by their glycosylated hemoglobin (A1C) values. By the end of 12 months, the difference in average A1C between the two groups had disappeared. But more patients in the experimental program lowered their A1C significantly during the study period, when compared to patients receiving standard care.

Paul C. Tang, MD, VP and chief innovation and technology officer at PAMF, and lead author of the study, told InformationWeek Healthcare that the group's excellent performance in diabetes care is one reason why the intensive online program did not have a greater effect on patient outcomes compared to usual care. PAMF has done a lot of work on disease management, especially in the diabetes area, and it also has good alerts and reminders in its EHR, he said. As a result, he said, 70% of PAMF's patients with diabetes have their condition under control, compared to an average of about 50% nationwide.

Tang said it was important that more patients in the intervention group than the usual-care group achieved a decrease in A1C levels. In fact, he said, that's a better quality measure than looking at the average A1C of a group of patients with diabetes, because it is a more accurate indicator of population health.

Tang's opinion on this matter carries a lot of weight, because he is vice chair of the Health IT Policy Committee, an industry group that advises the Office of the National Coordinator of Health IT (ONC) on issues related to Meaningful Use. In fact, Tang said the committee has discussed moving toward performance measures that show how many patients improved their conditions in stage 3 of Meaningful Use.

Another key finding was that patients in the intervention group had their medications changed or adjusted more often than those who received usual care. Tang pointed out that one reason many patients with diabetes are out of control is that they're not using the right medications or the right dosages or not taking them as prescribed. In the usual care group, physicians saw the patients two to four times a year; but the nurse case managers, who were empowered to make medication changes, had more frequent contact with the intervention patients.

"In between visits with the doctor, the nurse is watching over you and giving you advice," Tang noted. "If you're out of control and are getting worse, the nurse can intensify your medication, for example."

The fact that a care team led by nurse case managers could manage this population largely online, the study noted, opens up the possibility that patients with diabetes could safely see their doctors less often than they do now. "You can safely manage people and improve on the outcomes using primarily online tools," Tang said. "The nurses still could call patients and see them physically, but most of the interactions were online. That's important."

PAMF's research team is about to begin a new study of patients with uncontrolled hypertension, using the same principles as in the diabetes study, but measuring changes in patients' blood pressure, exercise and weight, Tang said. The study will use iPhones that have more capabilities than the now-extinct Palm Treo used in the earlier trial, he noted.

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